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Arizona Health Care Cost Containment System (AHCCCS) Companion Guide

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AHCCCS)

Standard Companion Guide Transaction Information

Instructions related to Transactions based on ASC X12 Implementation Guides, version 005010

Companion Guide Version Number: 0.2 October 1, 2010


OCTOBER 2010 ● 005010 2

© [insert copyright information here]


OCTOBER 2010 ● 005010 3

Table of Contents Transaction Instruction (TI) ............................................................................4

1. TI Introduction...............................................................................................4 1.1 Background ..............................................................................................4

1.1.1 Overview of HIPAA Legislation ......................................................4 1.1.2 Compliance according to HIPAA ....................................................4 1.1.3 Compliance according to ASC X12 ................................................4

1.2 Intended Use ............................................................................................5

2. Included ASC X12 Implementation Guides ................................................5

3. Instruction Tables.........................................................................................5 3.1 834 Benefit Enrollment and Maintenance ................................................5 3.2 820 Payroll Deducted and Other Group Premium Payment for Insurance

Products ................................................................................................8

4. TI Additional Information .............................................................................9 4.1 Business Scenarios..................................................................................9

4.1.1 834 Crib Notes ...............................................................................9 4.1.2 820 Examples...............................................................................44

4.2 Payer Specific Business Rules and Limitations .....................................62 4.2.1 834 Enrollment Transaction .........................................................62 4.2.2 820 Capitation Transaction ..........................................................62

4.3 Frequently Asked Questions ..................................................................64 4.4 Other Resources ....................................................................................64

4.4.1 AHCCCS Action Code Translation Table.....................................64

5. TI Change Summary ...................................................................................66


OCTOBER 2010 ● 005010 4

Transaction Instruction (TI) 1. TI Introduction

1.1 Background 1.1.1 Overview of HIPAA Legislation

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 carries provisions for administrative simplification. This requires the Secretary of the Department of Health and Human Services (HHS) to adopt standards to support the electronic exchange of administrative and financial health care transactions primarily between health care providers and plans. HIPAA directs the Secretary to adopt standards for translations to enable health information to be exchanged electronically and to adopt specifications for implementing each standard HIPAA serves to: • Create better access to health insurance • Limit fraud and abuse • Reduce administrative costs

1.1.2 Compliance according to HIPAA The HIPAA regulations at 45 CFR 162.915 require that covered entities not enter into a trading partner agreement that would do any of the following: • Change the definition, data condition, or use of a data

element or segment in a standard. • Add any data elements or segments to the maximum defined

data set. • Use any code or data elements that are marked “not used” in

the standard’s implementation specifications or are not in the standard’s implementation specification(s).

• Change the meaning or intent of the standard’s implementation specification(s).

1.1.3 Compliance according to ASC X12 ASC X12 requirements include specific restrictions that prohibit trading partners from: • Modifying any defining, explanatory, or clarifying content

contained in the implementation guide. • Modifying any requirement contained in the implementation

guide.


OCTOBER 2010 ● 005010 5

1.2 Intended Use The Transaction Instruction component of this companion guide must be used in conjunction with an associated ASC X12 Implementation Guide. The instructions in this companion guide are not intended to be stand-alone requirements documents. This companion guide conforms to all the requirements of any associated ASC X12 Implementation Guides and is in conformance with ASC X12’s Fair Use and Copyright statements.

2. Included ASC X12 Implementation Guides Unique ID Name [005010X220] Benefit Enrollment and Maintenance (834) [005010X218] Payroll Deducted and Other Group Premium Payment for Insurance Products

(820)

3. Instruction Tables 3.1 834 Benefit Enrollment and Maintenance

Loop ID Referenc

e Name Codes Notes/Comments

1000A N1 Sponsor Name 1000A N102 Name AHCCCS 1000A N104 Identification

Code 866004791

2320 COB Coordination of Benefits

2320 COB02 Reference Identification

TPL-INS-TYP (1) + TPL-POLICY-ID (20) or MEDICARE CLAIM ID NUMBER

Sent in 2300 COB loop only (when HD03=MM)


OCTOBER 2010 ● 005010 6

2320 REF Additional Coordination of Benefits Identifiers

2320 REF02 Reference Identification

INS-GRP-NUM or PART D DRUG PLAN ID NUMBER

Sent in 2300 COB loop only (when HD03=MM) Not used for Medicare Part A or B

2330 NM1 Coordination of Benefits Related Entity

2330 NM103 Name Last or Organization Name

MASTER CARRIER ID + CARRIER NAME/ MEDICARE PLAN NAME

Sent in 2300 COB loop only (when HD03=MM) If present, Medicare Part A Carrier ID = 00050, Medicare Part B Carrier ID = 00051 and Medicare Part D Carrier ID = 00052.

2750 REF Reporting Category Reference


Populated with an Action Code

2750 N1 Reporting Category

2750 N102 Name Prior Plan New Plan

Populated with literal “Prior Plan” only when last member enrollment was within 90 days and with a different plan. Populated with literal “New Plan” only when member is enrolled in a different plan the day after the term date.



Prior Plan uses: PRIOR PLAN ID (6) + PRIOR PLAN NAME (25) New Plan uses: HMO PLAN ID (6) + HMO PLAN NAME (25)


OCTOBER 2010 ● 005010 7


2750 REF02 Name MH CATEGORY CODE (1) + MH PROVIDER ID (6) + MH PROVIDER NAME (20)

Sent in 2750 when: N102=”BHS” and REF01=XX1



NURSING HOME ID (6) + NURSING HOME NAME (25) (or CASE WORKER ID [6] + CASE WORKER NAME [25])

Sent in 2750 when: N102=”LTC” and REF01=XX1



PLAN ID (5) + PLAN NAME (40)

Sent in 2750 when: N102="Medicare HMO" and REF01=PID


OCTOBER 2010 ● 005010 8

3.2 820 Payroll Deducted and Other Group Premium Payment for Insurance Products

Loop ID Reference Name Codes Notes/Comments 2300B RMR Individual

Premium Remittance Detail

2300B RMR02 Insurance Remittance Reference Number

Contract Type X(1) +

County X(2) + Rate Code X(4)

+ Voucher

Number X(9)

AHCCCS strings the following fixed-length fields: • Contract Type X(1) • County X(2) • Rate Code X(4) • Voucher Number X(9)


OCTOBER 2010 ● 005010 9

4. TI Additional Information 4.1 Business Scenarios

4.1.1 834 Crib Notes

Element Identifier Description U

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INTERCHANGE

ISA11 Repetition Separator R ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ISA12 Interchange Control

Version Number R 00501 00501 00501 00501 00501 00501 00501 00501 00501 00501 00501 00501 00501

FUNCTIONAL GROUP GS01 Functional Identifier

Code R ID 2-2 BE BE BE BE BE BE BE BE BE BE BE BE BE

GS08 Version / Release / Industry Identifier Code; no addenda

R AN 1-12

005010X220

005010X220

005010X220

005010X220

005010X220

005010X220

005010X220

005010X220

005010X220

005010X220

005010X220

005010X220

005010X220

HEADER ST Transaction Set

Header R

ST01 Transaction Set Identifier Code

R ID 3-3 834 834 834 834 834 834 834 834 834 834 834 834 834

ST02 Transaction Set Control Number

R AN 4-9

ST03 Implementation Convention Reference

R AN 1-35

005010X220

005010X220

005010X220

005010X220

005010X220

005010X220

005010X220

005010X220

005010X220

005010X220

005010X220

005010X220

005010X220

BGN Beginning Segment R BGN01 Transaction Set

Purpose Code R ID 2-2 00 00 00 00 00 00 00 00 00 00 00 00 00

BGN02 Reference Identification R AN 1-50

BGN03 Date R DT 8-8 PROCESS

DATE

PROCESS

DATE

PROCESS

DATE

PROCESS

DATE

PROCESS

DATE

PROCESS

DATE

PROCESS

DATE

PROCESS

DATE

PROCESS

DATE

PROCESS

DATE

PROCESS

DATE

PROCESS

DATE

PROCESS

DATE


OCTOBER 2010 ● 005010 10

Element Identifier Description

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BGN04 Time R TM 4-8 BGN05 Time Code S ID 2-2 BGN08 Action Code R ID 1-2 2 2 2 2 2 2 2 2 2 2 2 4 4 REF Transaction Set Policy

Number S

REF01 Reference Identification Qualifier

R ID 2-3 38 38 38 38 38 38 38 38 38 38 38 38 38

REF02 Reference Identification R AN 1-50

HP ID HP ID HP ID HP ID HP ID HP ID HP ID HP ID HP ID HP ID HP ID HP ID HP ID

DTP File Effective Date S DTP01 Date/Time Qualifier R ID 3-3 303 303 303 303 303 303 303 303 303 303 303 303 303 DTP02 Date Time Period

Format Qualifier R ID 2-3 D8 D8 D8 D8 D8 D8 D8 D8 D8 D8 D8 D8 D8

DTP03 Date Time Period R AN 1-35

QTY Transaction Set Control Totals

S

QTY01 Quantity Qualifier R ID 2-2 Use 'TO' Total TO TO TO TO TO TO TO TO TO TO TO TO TO QTY02 Quantity R R 1-

15 INS Count INS

Count INS Count

INS Count

INS Count

INS Count

INS Count

INS Count

INS Count

INS Count

INS Count

INS Count

INS Count

INS Count

1000A SPONSOR NAME( 1 )

N1 Sponsor Name R N101 Entity Identifier Code R ID 2-3 P5 P5 P5 P5 P5 P5 P5 P5 P5 P5 P5 P5 P5 N102 Name S AN 1-

60 AHCCC

S AHCCC

S AHCCC

S AHCCC

S AHCCC

S AHCCC

S AHCCC

S AHCCC

S AHCCC

S AHCCC

S AHCCC

S AHCCC

S AHCCC

S

N103 Identification Code Qualifier

R ID 1-2 FI FI FI FI FI FI FI FI FI FI FI FI FI

N104 Identification Code R AN 2-80

866004791

866004791

866004791

866004791

866004791

866004791

866004791

866004791

866004791

866004791

866004791

866004791

866004791

1000B PAYER ( 1 )

N1 Payer R N101 Entity Identifier Code R ID 2-3 IN IN IN IN IN IN IN IN IN IN IN IN IN


OCTOBER 2010 ● 005010 11


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N102 Name S AN 1-60

HP NAME

HP NAME

HP NAME

HP NAME

HP NAME

HP NAME

HP NAME

HP NAME

HP NAME

HP NAME

HP NAME

HP NAME

HP NAME

N103 Identification Code Qualifier

R ID 1-2 FI FI FI FI FI FI FI FI FI FI FI FI FI

N104 Identification Code R AN 2-80

HP TAX ID

HP TAX ID

HP TAX ID

HP TAX ID

HP TAX ID

HP TAX ID

HP TAX ID

HP TAX ID

HP TAX ID

HP TAX ID

HP TAX ID

HP TAX ID

HP TAX ID

2000 MEMBER LEVEL DETAIL( >1 )

INS Member Level Detail R INS01 Yes/No Condition or

Response Code R ID 1-1 Y Y Y Y Y Y Y Y Y Y Y Y Y

INS02 Individual Relationship Code

R ID 2-2 18 18 18 18 18 18 18 18 18 18 18 18 18

INS03 Maintenance Type Code

R ID 3-3 021 024 001 001 001 001 001 001 001 001 001 030 030

INS04 Maintenance Reason Code

S ID 2-3 02 - Birth28 – Initial Enrollment 41 - Re-enrollment

03 - Death 07 – Termination of Benefits14 - Voluntary Withdrawal 22 - Plan ChangeAH - Patient Moved

43 - Change of location

33 - Personnel Data

25 - Change in Identifying Data Element

22 - Plan Change

AI - No Reason Given

29 - Benefit Selection

33 - Personnel Data

AI - No Reason Given

XN - Notification Only

XN - Notification Only

INS05 Benefit Status Code R ID 1-1 A A A A A A A A A A A A A INS06-1 Medicare Plan Code R ID 1-1 MED-

CODE MED-CODE

MED-CODE

MED-CODE

MED-CODE

MED-CODE

MED-CODE

MED-CODE

MED-CODE

MED-CODE

MED-CODE

MED-CODE

MED-CODE

INS08 Employment Status Code

S ID 2-2 AC TE AC AC AC AC AC AC AC AC AC AC AC

INS11 Date Time Period Format Qualifier

S ID 2-3 D8 D8


OCTOBER 2010 ● 005010 12


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INS12 Date Time Period S AN 1-35

Use for Date of Death only, if present

DAT OF DTH

DAT OF DTH

REF Subscriber Identifier R


R ID 2-3 0F 0F 0F 0F 0F 0F 0F 0F 0F 0F 0F 0F 0F


AHCCCS ID

AHCCCS ID

AHCCCS ID

AHCCCS ID

AHCCCS ID

AHCCCS ID

AHCCCS ID

AHCCCS ID

AHCCCS ID

AHCCCS ID

AHCCCS ID

AHCCCS ID

"No Data"

REF Member Supplemental Identifier

S


R ID 2-3 3H-Case NumberQ4-Prior Identifier Number (Primary AHCCCS ID) 17-Client Reporting Category (Voucher Number)

3H Q4

17

3H Q4

17

3H

17

3H Q4

17


1) Case Number (when REF01=3H)2) Primary AHCCCS ID (when REF01=Q4) 3) Voucher Number (when REF01=17)

1) CASE ID 2) PRIMARY AHCCCS ID 3) VOUCHER NUMBER


1) CASE ID 3) VOUCHER NUMBER


DTP Member Level Dates S


OCTOBER 2010 ● 005010 13


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DTP01 Date/Time Qualifier R ID 3-3 356 357

356 357

303 303 303 303 303 303 303 303 303 303

DTP02 Date Time Period Format Qualifier

R ID 2-3 D8 D8 D8 D8 D8 D8 D8 D8 D8 D8 D8 D8


ENRL BEG

ENRL END

ENRL BEG

ENRL END

PROCESS

DATE

PROCESS

DATE

PROCESS

DATE

PROCESS

DATE

PROCESS

DATE

PROCESS

DATE

PROCESS

DATE

PROCESS

DATE

PROCESS

DATE

PROCESS

DATE

2100A MEMBER NAME ( 1 )

R

NM1 Member Name R NM101 Entity Identifier Code R ID 2-3 IL IL IL IL IL

74 IL IL IL IL IL IL IL IL

NM102 Entity Type Qualifier R ID 1-1 1 1 1 1 1 1 1 1 1 1 1 1 1 NM103 Name Last or

Organization Name R AN 1-

60 LAST

NAME LAST NAME

LAST NAME

LAST NAME

LAST NAME

LAST NAME

LAST NAME

LAST NAME

LAST NAME

LAST NAME

LAST NAME

LAST NAME

"No Last Name"

NM104 Name First S AN 1-35

FIRST NAME

FIRST NAME

FIRST NAME

FIRST NAME

FIRST NAME

FIRST NAME

FIRST NAME

FIRST NAME

FIRST NAME

FIRST NAME

FIRST NAME

FIRST NAME

"No First Name"

NM105 Name Middle S AN 1-25

MIDDLE INIT

MIDDLE INIT

MIDDLE INIT

MIDDLE INIT

MIDDLE INIT

MIDDLE INIT

MIDDLE INIT

MIDDLE INIT

MIDDLE INIT

MIDDLE INIT

MIDDLE INIT

MIDDLE INIT

PER Member Communications Numbers

S

PER01 Contact Function Code R ID 2-2 IP IP IP PER03 Communication Number

Qualifier R ID 2-2 HP HP HP

PER04 Communication Number R AN 1-256

HOME PHONE

HOME PHONE

HOME PHONE

PER05 Communication Number Qualifier

S ID 2-2 TE TE TE

PER06 Communication Number S AN 1-256

EMER PHONE

EMER PHONE

EMER PHONE

N3 Member Residence Street Address

S


OCTOBER 2010 ● 005010 14


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N301 Address Information R AN 1-55

Needed until Errata approved

RES STR1

RES STR1

RES STR1

RES STR1

RES STR1

RES STR1

RES STR1

RES STR1

RES STR1

RES STR1

RES STR1

RES STR1

N302 Address Information S AN 1-55

RES STR2

RES STR2

RES STR2

RES STR2

RES STR2

RES STR2

RES STR2

RES STR2

RES STR2

RES STR2

RES STR2

RES STR2

N4 Member Residence City, State, ZIP Code

S

N401 City Name R AN 2-30

CITY CITY CITY CITY CITY CITY CITY CITY CITY CITY CITY CITY

N402 State or Province Code S AN 2-2 STATE STATE STATE STATE STATE STATE STATE STATE STATE STATE STATE STATE N403 Postal Code S ID 3-

15 ZIP ZIP ZIP ZIP ZIP ZIP ZIP ZIP ZIP ZIP ZIP ZIP

N405 Location Qualifier S ID 1-2 CY CY CY CY CY CY CY CY CY CY CY CY N406 Location Identifier S AN 1-

30 CTY

CODE CTY

CODE CTY

CODE CTY

CODE CTY

CODE CTY

CODE CTY

CODE CTY

CODE CTY

CODE CTY

CODE CTY

CODE CTY

CODE

DMG Member Demographics

S

DMG01 Date Time Period Format Qualifier

R ID 2-3 D8 D8 D8 D8

DMG02 Date Time Period R AN 1-35

DOB DOB DOB DOB

DMG03 Gender Code R ID 1-1 GENDER

GENDER

GENDER

GENDER

DMG04 Marital Status Code S ID 1-1 MARITAL STA

MARITAL STA

DMG05-1

Race or Ethnicity Code S ID 1-1 ETHNICITY

ETHNICITY

LUI Member Language S LUI01 Identification Code

Qualifier S ID 1-2 LE LE

LUI02 Identification Code S AN 2-80

LANGUAGE

LANGUAGE

LUI04 Use of Language Indicator

S ID 1-2 6 6


OCTOBER 2010 ● 005010 15


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2100B INCORRECT MEMBER NAME( 1 )

Sent on Name change actions only; not used on monthly

NM1 Incorrect Member Name

S

NM101 Entity Identifier Code R ID 2-3 70 NM102 Entity Type Qualifier R ID 1-1 1 NM103 Name Last or


60 PRIOR

LAST NAME


PRIOR FIRST NAME


PRIOR MI

DMG Incorrect Member Demographics

S Used when Action code ≠ NC (Name change); not used on monthly

DMG01 Date Time Period Format Qualifier

S ID 2-3 D8

DMG02 Date Time Period S AN 1-35

PRIOR DOB

DMG03 Gender Code S ID 1-1 PRIOR GENDE

R

2100C MEMBER MAILING ADDRESS ( 1 )

Only present if different from Residential Address

NM1 Member Mailing Address

S

NM101 Entity Identifier Code R ID 2-3 31 31 31 NM102 Entity Type Qualifier R ID 1-1 1 1 1


OCTOBER 2010 ● 005010 16


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N3 Member Mail Street Address

S


MAIL STR1

MAIL STR1

MAIL STR1


MAIL STR2

MAIL STR2

MAIL STR2

N4 Member Mail City, State, Zip

S


MAIL CITY

MAIL CITY

MAIL CITY

N402 State or Province Code S AN 2-2 MAIL ST MAIL ST MAIL ST N403 Postal Code S ID 3-

15 MAIL

ZIP MAIL

ZIP MAIL

ZIP

2100G RESPONSIBLE PERSON ( 13 )

Mother's information on Newborn Adds only (when INS04='02' Birth)

NM1 Responsible Person S NM101 Entity Identifier Code R ID 2-3 S1 NM102 Entity Type Qualifier R ID 1-1 1 NM103 Name Last or


60 MOM-

LAST-NAME


MOM-FIRST-NAME


MOM-MI

NM108 Identification Code Qualifier

S ID 1-2 ZZ

NM109 Identification Code S AN 2-80

MOM-ID (9) +

MOM-CASE-ID

(9)


OCTOBER 2010 ● 005010 17


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N3 Responsible Person Street Address

S


RES-STR-1


RES-STR-2

N4 Responsible Person City, State, Zip

R


RES-CITY

N402 State or Province Code S ID 2-2 RES-ST N403 Postal Code S ID 3-

15 5 or 9 digit Zip Code

RES-ZIP

2300 HEALTH COVERAGE( 99 )

HMO LOOP

HD Health Coverage S HD01 Maintenance Type

Code R ID 3-3

021

030

HD03 Insurance Line Code R ID 2-3 HMO HMO DTP Health Coverage

Dates R


348


R ID 2-3 D8 D8


Begin Date End Date

Begin Date


OCTOBER 2010 ● 005010 18


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PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

B

DA

ILY

ON

1st

O

F M

ON

TH

MO

NTH

LY

EM

PTY

AMT Health Coverage Policy

S

AMT01 Amount Qualifier Code R ID 1-3 AMT02 Monetary Amount R R 1-

18

REF Health Coverage Policy Number

S


R ID 2-3 CE CE


Contract Type

Contract Type

2320 COORDINATION OF BENEFITS ( 5 )

COB Coordination of Benefits

S

COB01 Payer Responsibility Sequence Number Code

R ID 1-1

COB02 Reference Identification S AN 1-50

COB03 Coordination of Benefits Code

R ID 1-1

REF Additional Coordination of Benefits Identifiers

S


R ID 2-3


DTP Coordination of Benefits Eligibility Dates

S

DTP01 Date/Time Qualifier R ID 3-3


OCTOBER 2010 ● 005010 19


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AHCCCS Note

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D

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LL

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S

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CO

PA

Y

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AN

GE

DO

B N

AM

E S

EX

C

HA

NG

E

MH

CH

AN

GE

O

R T

ER

M

PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

B

DA

ILY

ON

1st

O

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ON

TH

MO

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EM

PTY


R ID 2-3


2330 COORDINATION OF BENEFITS RELATED ENTITY( 3 )

NM1 Coordination of Benefits Related Entity

S Note: This segment partially existed in 4010 at 2320/N1.

NM101 Entity Identifier Code R ID 2-3 NM102 Entity Type Qualifier S ID 1-1 NM103 Name Last or

Organization Name S AN 1-

60

N3 Coordination of Benefits Related Entity Address

S


N4 Coordination of Benefits Other Insurance Company City, State, ZIP Code

R


N402 State or Province Code S ID 2-2 N403 Postal Code S ID 3-

15

PER Administrative Communications Contact

S

PER01 Contact Function Code R ID 2-2


OCTOBER 2010 ● 005010 20


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AHCCCS Note

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D

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CO

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CH

AN

GE

DO

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AM

E S

EX

C

HA

NG

E

MH

CH

AN

GE

O

R T

ER

M

PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

B

DA

ILY

ON

1st

O

F M

ON

TH

MO

NTH

LY

EM

PTY

PER03 Communication Number Qualifier

R ID 2-2


2300 HEALTH

COVERAGE ( 99 )

SOC LOOP


Code R ID 3-3

021 001

030

HD03 Insurance Line Code R ID 2-3 LTC LTC LTC DTP Health Coverage

Dates R

DTP01 Date/Time Qualifier R ID 3-3 348

348 348


R ID 2-3 D8 D8 D8


SOC Begin Date

SOC Begin Date

SOC Begin Date


S

AMT01 Amount Qualifier Code R ID 1-3 C1 C1 C1 AMT02 Monetary Amount R R 1-

18 SOC-

AMT SOC-

AMT SOC-

AMT


S


R ID 2-3



OCTOBER 2010 ● 005010 21


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AHCCCS Note

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CH

AN

GE

DO

B N

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E S

EX

C

HA

NG

E

MH

CH

AN

GE

O

R T

ER

M

PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

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DA

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ON

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TH

MO

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EM

PTY



S


R ID 1-1



R ID 1-1


S


R ID 2-3



S

DTP01 Date/Time Qualifier R ID 3-3 DTP02 Date Time Period

Format Qualifier R ID 2-3


2330 COORDINATION OF BENEFITS RELATED ENTITY ( 3 )




OCTOBER 2010 ● 005010 22


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AHCCCS Note

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AN

GE

DO

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AM

E S

EX

C

HA

NG

E

MH

CH

AN

GE

O

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ER

M

PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

B

DA

ILY

ON

1st

O

F M

ON

TH

MO

NTH

LY

EM

PTY

NM101 Entity Identifier Code R ID 2-3 NM102 Entity Type Qualifier S ID 1-1 NM103 Name Last or


60


S



R


N402 State or Province Code S ID 2-2 N403 Postal Code S ID 3-

15


S

PER01 Contact Function Code R ID 2-2 PER03 Communication Number

Qualifier R ID 2-2


2300 HEALTH

COVERAGE ( 99 )

COB LOOP


Code R ID 3-3 001

HD03 Insurance Line Code R ID 2-3 Distinguishes the COB loop

MM


OCTOBER 2010 ● 005010 23


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AHCCCS Note

AD

D

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RO

LL

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S

CH

AN

GE

CO

PA

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CH

AN

GE

DO

B N

AM

E S

EX

C

HA

NG

E

MH

CH

AN

GE

O

R T

ER

M

PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

B

DA

ILY

ON

1st

O

F M

ON

TH

MO

NTH

LY

EM

PTY

DTP Health Coverage Dates

R

DTP01 Date/Time Qualifier R ID 3-3 348


R ID 2-3 D8


Begin Date


S

AMT01 Amount Qualifier Code R ID 1-3 AMT02 Monetary Amount R R 1-

18


S


R ID 2-3




S


R ID 1-1 U


OCTOBER 2010 ● 005010 24


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AHCCCS Note

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CO

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AN

GE

DO

B N

AM

E S

EX

C

HA

NG

E

MH

CH

AN

GE

O

R T

ER

M

PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

B

DA

ILY

ON

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O

F M

ON

TH

MO

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LY

EM

PTY


TPL-INS-TYP

(1) + TPL-

POLICY-ID (20)

or MEDICA

RE CLAIM

ID NUMBE

R


R ID 1-1 5


S


R ID 2-3 6P-Group number 6P


Not used for Medicare Part A or B

INS-GRP-NUM

or PART D DRUG

PLAN ID NUMBE

R


S


R ID 2-3 60-Account Suffix code

60


TPL-SEQ-NO


S


OCTOBER 2010 ● 005010 25


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AHCCCS Note

AD

D

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CO

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CH

AN

GE

DO

B N

AM

E S

EX

C

HA

NG

E

MH

CH

AN

GE

O

R T

ER

M

PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

B

DA

ILY

ON

1st

O

F M

ON

TH

MO

NTH

LY

EM

PTY



R ID 2-3 D8


Begin Date End Date

2330 COORDINATION OF BENEFITS RELATED ENTITY ( 3 )



NM101 Entity Identifier Code R ID 2-3 IN NM102 Entity Type Qualifier S ID 1-1 2 NM103 Name Last or


60 If present, Medicare Part A Carrier ID = 00050,Medicare Part B Carrier ID = 00051 and Medicare Part D Carrier ID = 00052.

MASTER

CARRIER ID +

CARRIER

NAME/MEDICARE PLAN NAME


S


OCTOBER 2010 ● 005010 26


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AHCCCS Note

AD

D

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EN

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LL

AD

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ES

S

CH

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GE

CO

PA

Y

CH

AN

GE

DO

B N

AM

E S

EX

C

HA

NG

E

MH

CH

AN

GE

O

R T

ER

M

PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

B

DA

ILY

ON

1st

O

F M

ON

TH

MO

NTH

LY

EM

PTY


TPL address, if known, else "No Address Known" (No address known/stored for Medicare Part A, B or D.)

TPL-STR-1

or "No

Address Known" (Medicar

e Part A/B)


TPL address, if present, (No address known/stored for Medicare Part A, B or D.)

TPL-STR-2


R


TPL address, if known, else "No City" (No address known/stored for Medicare Part A, B or D.)

TPL-CITY

or "No City"

N402 State or Province Code S ID 2-2 TPL address, if known, else "AZ" (No address known/stored for Medicare Part A, B or D.)

TPL-STATE

or "AZ"


OCTOBER 2010 ● 005010 27


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AHCCCS Note

AD

D

DIS

EN

RO

LL

AD

DR

ES

S

CH

AN

GE

CO

PA

Y

CH

AN

GE

DO

B N

AM

E S

EX

C

HA

NG

E

MH

CH

AN

GE

O

R T

ER

M

PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

B

DA

ILY

ON

1st

O

F M

ON

TH

MO

NTH

LY

EM

PTY

N403 Postal Code S ID 3-15

TPL address, if known, else "85034" (No address known/stored for Medicare Part A, B or D.)

TPL-ZIPor

"85034"


S TPL Phone Number, if present, else not used.

PER01 Contact Function Code R ID 2-2 CN PER03 Communication Number

Qualifier R ID 2-2 TE


TPL-PHONE

2700 ADDITIONAL REPORTING CATEGORIES( 1 )

LS Additional Reporting Categories

LS01 Loop Identifier Code R AN 1-4 2700 2700 2700 2700 2700 2700 2700 2700 2700 2700 2700 2710 MEMBER

REPORTING CATEGORIES ( >1 )

LX Member Reporting Categories

S ACTION CODE

LX01 Assigned Number R N0 1-6 Incrementing number


OCTOBER 2010 ● 005010 28


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ID

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ax

AHCCCS Note

AD

D

DIS

EN

RO

LL

AD

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ES

S

CH

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GE

CO

PA

Y

CH

AN

GE

DO

B N

AM

E S

EX

C

HA

NG

E

MH

CH

AN

GE

O

R T

ER

M

PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

B

DA

ILY

ON

1st

O

F M

ON

TH

MO

NTH

LY

EM

PTY

2750 REPORTING CATEGORY ( 1 )

N1 Reporting Category S N101 Entity Identifier Code R ID 2-3 75 75 75 75 75 75 75 75 75 N102 Name R AN 1-

60 "Action

Code" "Action Code"

"Action Code"

"Action Code"

"Action Code"

"Action Code"

"Action Code"

"Action Code"

"Action Code"

REF Reporting Category Reference

S


R ID 2-3 ZZ ZZ ZZ ZZ ZZ ZZ ZZ ZZ ZZ


ACTION CODE

ACTION CODE

ACTION CODE

ACTION CODE

ACTION CODE

ACTION CODE

ACTION CODE

ACTION CODE

ACTION CODE

DTP Reporting Category Date

S




2710 MEMBER



S RATE CODE



N1 Reporting Category S N101 Entity Identifier Code R ID 2-3 75 75 75


OCTOBER 2010 ● 005010 29


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ax

AHCCCS Note

AD

D

DIS

EN

RO

LL

AD

DR

ES

S

CH

AN

GE

CO

PA

Y

CH

AN

GE

DO

B N

AM

E S

EX

C

HA

NG

E

MH

CH

AN

GE

O

R T

ER

M

PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

B

DA

ILY

ON

1st

O

F M

ON

TH

MO

NTH

LY

EM

PTY

N102 Name R AN 1-60

"Rate Code"

"Rate Code"

"Rate Code"


S


R ID 2-3 9V 9V 9V


RATE CODE

RATE CODE

RATE CODE


S

DTP01 Date/Time Qualifier R ID 3-3 007 007 DTP02 Date Time Period

Format Qualifier R ID 2-3 D8 D8


Begin Date

Begin Date

2710 MEMBER



S PRIOR PLAN



N1 Reporting Category S N101 Entity Identifier Code R ID 2-3 75 75


OCTOBER 2010 ● 005010 30


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AHCCCS Note

AD

D

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EN

RO

LL

AD

DR

ES

S

CH

AN

GE

CO

PA

Y

CH

AN

GE

DO

B N

AM

E S

EX

C

HA

NG

E

MH

CH

AN

GE

O

R T

ER

M

PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

B

DA

ILY

ON

1st

O

F M

ON

TH

MO

NTH

LY

EM

PTY

N102 Name R AN 1-60

ADD - Use Prior Plan only when last member enrollment was within 90 days and with a different plan. DISENROLL - Use New Plan only when member is enrolled in a different plan the day after the term date.

"Prior Plan"

"New Plan"


S


R ID 2-3 18 18


ADD - Use Prior Plan only when last member enrollment was within 90 days and with a different plan. DISENROLL - Use New Plan only when member is enrolled in a different plan the day after the term date.

PRIOR PLAN ID

(6) + PRIOR PLAN NAME

(25)

NEW PLAN ID

(6) + NEW PLAN NAME

(25)


S




OCTOBER 2010 ● 005010 31


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ID

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AHCCCS Note

AD

D

DIS

EN

RO

LL

AD

DR

ES

S

CH

AN

GE

CO

PA

Y

CH

AN

GE

DO

B N

AM

E S

EX

C

HA

NG

E

MH

CH

AN

GE

O

R T

ER

M

PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

B

DA

ILY

ON

1st

O

F M

ON

TH

MO

NTH

LY

EM

PTY


2710 MEMBER



S CO-PAY LEVEL



N1 Reporting Category S N101 Entity Identifier Code R ID 2-3 75 75 75 N102 Name R AN 1-

60 "Co-Pay

Level" "Co-Pay

Level" "Co-Pay

Level"


S


R ID 2-3 9X 9X 9X


CO-PAY LEVEL NUMBE

R

CO-PAY LEVEL NUMBE

R

CO-PAY LEVEL NUMBE

R


S

DTP01 Date/Time Qualifier R ID 3-3 007 007 007 DTP02 Date Time Period

Format Qualifier R ID 2-3 D8 D8 D8


Co-Pay Effective

Begin Date

Co-Pay Effective

Begin Date

Co-Pay Effective

Begin Date


OCTOBER 2010 ● 005010 32


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AHCCCS Note

AD

D

DIS

EN

RO

LL

AD

DR

ES

S

CH

AN

GE

CO

PA

Y

CH

AN

GE

DO

B N

AM

E S

EX

C

HA

NG

E

MH

CH

AN

GE

O

R T

ER

M

PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

B

DA

ILY

ON

1st

O

F M

ON

TH

MO

NTH

LY

EM

PTY

2710 MEMBER REPORTING CATEGORIES ( >1 )


S MH CATEGORY




60 "BHS" "BHS" "BHS"


S


R ID 2-3 XX1 XX1 XX1


MH CATEG

ORY CODE (1) + MH

PROVIDER ID (6) + MH

PROVIDER

NAME (20)

MH CATEG

ORY CODE (1) + MH


PROVIDER

NAME (20)

MH CATEG

ORY CODE (1) + MH


PROVIDER

NAME (20)


S

DTP01 Date/Time Qualifier R ID 3-3 007 007 007


OCTOBER 2010 ● 005010 33


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ID

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AHCCCS Note

AD

D

DIS

EN

RO

LL

AD

DR

ES

S

CH

AN

GE

CO

PA

Y

CH

AN

GE

DO

B N

AM

E S

EX

C

HA

NG

E

MH

CH

AN

GE

O

R T

ER

M

PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

B

DA

ILY

ON

1st

O

F M

ON

TH

MO

NTH

LY

EM

PTY


R ID 2-3 D8

RD8

D8

RD8

D8


ADD action = Begin Date or Begin Date through End Date; CHANGE action = Begin Date or Begin Date through End Date; TERM action = End Date

Begin Date

Begin Date-End Date

Begin Date

or End Date

Begin Date-End Date

Begin Date

LX Member Reporting

Categories S NICU




60 "NICU" "NICU" "NICU"


S




NI NI NI


S


OCTOBER 2010 ● 005010 34


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AHCCCS Note

AD

D

DIS

EN

RO

LL

AD

DR

ES

S

CH

AN

GE

CO

PA

Y

CH

AN

GE

DO

B N

AM

E S

EX

C

HA

NG

E

MH

CH

AN

GE

O

R T

ER

M

PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

B

DA

ILY

ON

1st

O

F M

ON

TH

MO

NTH

LY

EM

PTY




2710 MEMBER



S PG INDICATOR




60 "Pregnan

cy" "Pregnan

cy" "Pregnan

cy"


S




PG PG PG


S

DTP01 Date/Time Qualifier R ID 3-3 007 007 007 DTP02 Date Time Period

Format Qualifier R ID 2-3 D8 D8 D8


EXPECTED

DELIVE

EXPECTED

DELIVE

EXPECTED

DELIVE


OCTOBER 2010 ● 005010 35


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AHCCCS Note

AD

D

DIS

EN

RO

LL

AD

DR

ES

S

CH

AN

GE

CO

PA

Y

CH

AN

GE

DO

B N

AM

E S

EX

C

HA

NG

E

MH

CH

AN

GE

O

R T

ER

M

PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

B

DA

ILY

ON

1st

O

F M

ON

TH

MO

NTH

LY

EM

PTY

RY DATE

RY DATE

RY DATE

2710 MEMBER



S LTC For Long Term Care recipients

only.



N1 Reporting Category S N101 Entity Identifier Code R ID 2-3 75 75 N102 Name R AN 1-

60 "LTC" "LTC"


S


R ID 2-3 XX1 XX1


NURSING HOME ID (6) + NURSING HOME

NAME (25) (or

CASE WORKER ID [6] + CASE

NURSING HOME ID (6) + NURSING HOME

NAME (25) (or

CASE WORKER ID [6] + CASE


OCTOBER 2010 ● 005010 36


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eq

ID

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- M

ax

AHCCCS Note

AD

D

DIS

EN

RO

LL

AD

DR

ES

S

CH

AN

GE

CO

PA

Y

CH

AN

GE

DO

B N

AM

E S

EX

C

HA

NG

E

MH

CH

AN

GE

O

R T

ER

M

PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

B

DA

ILY

ON

1st

O

F M

ON

TH

MO

NTH

LY

EM

PTY

WORKER NAME

[25])

WORKER NAME

[25])


S




2710 MEMBER



S LTC TRANSITION INDICATOR

For Long Term Care recipients

only.



N1 Reporting Category S N101 Entity Identifier Code R ID 2-3 75 75


OCTOBER 2010 ● 005010 37


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eq

ID

Min

- M

ax

AHCCCS Note

AD

D

DIS

EN

RO

LL

AD

DR

ES

S

CH

AN

GE

CO

PA

Y

CH

AN

GE

DO

B N

AM

E S

EX

C

HA

NG

E

MH

CH

AN

GE

O

R T

ER

M

PR

EG

NA

NC

Y

OR

NIC

U

RA

TE C

OD

E

CH

AN

GE

SO

C C

HA

NG

E

CO

B

DA

ILY

ON

1st

O

F M

ON

TH

MO

NTH

LY

EM

PTY

N102 Name R AN 1-60

"Transition

Indicator"

"Transition

Indicator"


S


R ID 2-3 XX1 XX1


Y Y


S




2710 MEMBER



S AZEIP



N1 Reporting Category S N101 Entity Identifier Code R ID 2-3 75 N102 Name R AN 1-

60 "AZEIP"


S


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R ID 2-3 PID


AZEIP CLIENT

ID


S




2710 MEMBER



S CRS




60 "CRS"


S


R ID 2-3 PID


CRS CLIENT

ID


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S




2710 MEMBER



S MEDICARE HMO




60 "Medicar

e HMO"


S


R ID 2-3 PID


PLAN ID (5) + PLAN NAME

(40)


S

DTP01 Date/Time Qualifier R ID 3-3


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R ID 2-3


2710 MEMBER



S TSC




60 "TSC"


S


R ID 2-3 PID


TSC CLIENT

ID


S





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2710 MEMBER REPORTING CATEGORIES ( >1 )


S LTC PLACEMENT



N1 Reporting Category S N101 Entity Identifier Code R ID 2-3 75 75 75 75 N102 Name R AN 1-

60 "LTC

PLACEMENT"

"LTC PLACEM

ENT"

"LTC PLACEM

ENT"

"LTC PLACEM

ENT"


S


R ID 2-3 LU-Location Number

LU LU LU LU


PLACEMENT

CODE

PLACEMENT

CODE

PLACEMENT

CODE

PLACEMENT

CODE


S

DTP01 Date/Time Qualifier R ID 3-3 007 007 007 007 DTP02 Date Time Period

Format Qualifier R ID 2-3 RD8 RD8 RD8 RD8


BEGIN/END

DATE

BEGIN/END

DATE

BEGIN/END

DATE

BEGIN/END

DATE

2710 MEMBER



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S LTC RESIDENCE



N1 Reporting Category S N101 Entity Identifier Code R ID 2-3 75 75 75 75 N102 Name R AN 1-

60 "LTC

RESIDENCE"

"LTC RESIDE

NCE"

"LTC RESIDE

NCE"

"LTC RESIDE

NCE"


S


R ID 2-3 LU LU LU LU


RESIDENCE

CODE

RESIDENCE

CODE

RESIDENCE

CODE

RESIDENCE

CODE


S

DTP01 Date/Time Qualifier R ID 3-3 007 007 007 007 DTP02 Date Time Period

Format Qualifier R ID 2-3 RD8 RD8 RD8 RD8


BEGIN/END

DATE

BEGIN/END

DATE

BEGIN/END

DATE

BEGIN/END

DATE

LE Additional reporting

Categories Loop Termination

LE01 Loop Identifier Code R AN 1-4 2700 2700 2700 2700 2700 2700 2700 2700 2700 2700 2700 2700 TRAILER SE Transaction Set Trailer R


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SE01 Number of Included Segments

R N0 1-10

SE02 Transaction Set Control Number

R AN 4-9


OCTOBER 2010 ● 005010 44

4.1.2 820 Examples

4.1.2.1 Normal 820 Example Member #1 – Normal capitation payment of $89.30 for 10/01/09-10/14/09 Member #2 – Recoupment amount of $-94.06 for 10/01/09-10/31/09 and a capitation payment of $54.62 for 10/01/09-10/18/09. Note that Member #2 has one occurrence of the 2000B/ENT loop with multiple 2300/RMR loops. This a change from the 4010 to the 5010 for AZ

Element Identifier Description Values ISA08 Interchange Receiver ID 990123456 (HP TAX ID; 3-

character Health Plan acronym removed)

ISA11 Repetition Separator ^ ISA12 Interchange Control Version

Number 00501 GS01 Functional Identifier Code RA GS02 Application Sender’s Code AHCCCS866004791 GS03 Application Receiver’s Code 010101 GS04 Functional group creation date CCYYMMDD GS05 Time 02190182 GS06 Group Control Number 294021901 GS07 Responsible Agency Code X GS08 Version / Release / Industry

Identifier Code; no addenda 005010X218

ST 820 Header ST01 Transaction Set Identifier Code 820

ST02 Transaction Set Control Number 000000001

ST03 Implementation Convention Reference 005010X218

BPR Financial Information BPR01 Transaction Handling Code I - Remittance Info Only BPR02 Total Premium Payment

Amount 49.86

BPR03 Credit/Debit Flag Code C BPR04 Payment Method Code NON - Non-payment Data BPR10 Originating Company Identifier 1866004791 BPR16 Check Issue or EFT Effective

Date 20091028

TRN Reassociation Trace Number TRN01 Trace Type Code 3 - Financial Reassociation

Trace Number TRN02 Reference Identification 000000000075939 TRN03 Originating Company Identifier 1866004791

REF Premium Receivers Identification Key


14-Master Account Number


OCTOBER 2010 ● 005010 45

Element Identifier Description Values REF02 Premium Receiver Reference

Identifier 010101

DTM Coverage Period DTM01 Date/Time Qualifier 582 - Report Period DTM05 Date Time Period Format

Qualifier RD8

DTM06 Coverage Period 20091001-20091031 1000A PREMIUM RECEIVER’S

NAME

N1 Premium Receiver’s Name N101 Entity Identifier Code PE-Payee N102 Premium Receiver’s Last or

Organization Name AZ HEALTH PLAN

N3 Premium Receiver’s Address N301 Address Information 123 ADDRESS1 ST N302 Address Information SUITE #99

N4 Premium Receiver’s City, State, and Zip Code

N401 City Name PHOENIX N402 State or Province Code AZ N403 Postal Code 85034

1000B PREMIUM PAYER’S NAME

N1 Premium Payer’s Name N101 Entity Identifier Code PR N102 Premium Payer Name AHCCCS

N3 Premium Payer’s Address N301 Premium Payer Address Line 801 E JEFFERSON ST

N4 Premium Payer’s City, State, Zip Code


2000B INDIVIDUAL REMITTANCE

MEMBER #1

ENT Individual Remittance ENT01 Assigned Number 1 ENT02 Entity Identifier Code 2J - Individual ENT03 Identification Code Qualifier EI – Employee Identification

Number ENT04 Identification Code A01234567

2100B INDIVIDUAL NAME NM1 Individual Name

NM101 Entity Identifier Code IL - Insured/Subscriber ID NM102 Entity Type Qualifier 1 - Person NM103 Name Last or Organization

Name REGAN

NM104 Name First RONALD NM105 Name Middle A


OCTOBER 2010 ● 005010 46

Element Identifier Description Values NM108 Identification Code Qualifier N - Insured's Unique

Identification Number NM109 Identification Code A01234567

2300B INDIVIDUAL PREMIUM RMR Individual Premium Remittance

Detail

RMR01 Reference Identification Qualifier

AZ - Health Insurance Policy Number

RMR02 Insurance Remittance Reference Number

H19101FH0037918220091001

RMR04 Detail Premium Payment Amount

89.30

DTM Individual Coverage Period DTM01 Date/Time Qualifier 582 - Report Period DTM05 Date Time Period Format

Qualifier RD8

DTM06 Date Time Period 20091001-20091014 2000B INDIVIDUAL

REMITTANCE MEMBER#2

ENT Individual Remittance ENT01 Assigned Number 2 ENT02 Entity Identifier Code 2J - Individual ENT03 Identification Code Qualifier EI – Employee Identification

Number ENT04 Identification Code A07654321


NM101 Entity Identifier Code IL - Insured/Subscriber ID NM102 Entity Type Qualifier 1 - Person NM103 Name Last or Organization

Name REGAN

NM104 Name First NANCY NM105 Name Middle A NM108 Identification Code Qualifier N - Insured's Unique

Identification Number NM109 Identification Code A07654321

2300B INDIVIDUAL PREMIUM OCCURRENCE #1 RMR Individual Premium Remittance

Detail


AZ - Helath Insurance Policy Number


A191012H0037944520091001


-94.06


Qualifier RD8


OCTOBER 2010 ● 005010 47

Element Identifier Description Values DTM06 Date Time Period 20091001-20091031

2300B INDIVIDUAL PREMIUM OCCURRENCE #2 RMR Individual Premium Remittance

Detail


AZ - Health Insurance Policy Number


A191012H0037944520091001


54.62


Qualifier RD8

DTM06 Date Time Period 20091001-20091018 SE Transaction Set Trailer

SE01 Number of Included Segments SE02 Transaction Set Control

Number

4.1.2.2 Sanction Adjustment Example Total 820 Payment amount: $149.86 Total Remittances: $249.86 Sanction amount: $-100.00 Member #1 – Normal capitation payment of $89.30 for 10/01/09-10/14/09 Member #2 – Recoupment amount of $-94.06 for 10/01/09-10/31/09 and a capitation payment of $54.62 for 10/01/09-10/18/09. Note that Member #2 has one occurrence of the 2000B/ENT loop with multiple 2300/RMR loops. This a change from the 4010 to the 5010 for AZ Element Identifier Description Values ISA08 Interchange Receiver ID 990123456 (3-character Health Plan

acronym removed) ISA11 Repetition Separator ^ ISA12 Interchange Control Version Number 00501 GS01 Functional Identifier Code RA GS02 Application Sender’s Code AHCCCS866004791 GS03 Application Receiver’s Code 010101 GS04 Functional group creation date CCYYMMDD GS05 Time 02190182 GS06 Group Control Number 294021901 GS07 Responsible Agency Code X

GS08 Version / Release / Industry Identifier Code; no addenda 005010X218

ST 820 Header ST01 Transaction Set Identifier Code 820 ST02 Transaction Set Control Number 000000001


OCTOBER 2010 ● 005010 48

Element Identifier Description Values ST03 Implementation Convention Reference 005010X218

BPR Financial Information BPR01 Transaction Handling Code I - Remittance Info Only BPR02 Total Premium Payment Amount 149.86 BPR03 Credit/Debit Flag Code C BPR04 Payment Method Code NON - Non-payment Data BPR10 Originating Company Identifier 1866004791 BPR16 Check Issue or EFT Effective Date 20091028

TRN Reassociation Trace Number TRN01 Trace Type Code 3 - Financial Reassociation Trace

Number TRN02 Reference Identification 000000000075939 TRN03 Originating Company Identifier 1866004791

REF Premium Receivers Identification Key REF01 Reference Identification Qualifier 14-Master Account Number REF02 Premium Receiver Reference Identifier 010101

DTM Coverage Period DTM01 Date/Time Qualifier 582 - Report Period DTM05 Date Time Period Format Qualifier RD8 DTM06 Coverage Period 20091001-20091031

1000A PREMIUM RECEIVER’S NAME N1 Premium Receiver’s Name

N101 Entity Identifier Code PE-Payee

N102 Premium Receiver’s Last or Organization Name AZ HEALTH PLAN




1000B PREMIUM PAYER’S NAME N1 Premium Payer’s Name

N101 Entity Identifier Code PR N102 Premium Payer Name AHCCCS


N4 Premium Payer’s City, State, Zip Code N401 City Name PHOENIX N402 State or Province Code AZ N403 Postal Code 85034

2000A ORGANIZATION SUMMARY ENT Organization Summary Remittance

ENT01 Assigned Number 1 ENT02 Entity Identifier Code AG - Agency ENT03 Identification Code Qualifier FI - Federal Tax Identification Number ENT04 Identification Code 866004791


OCTOBER 2010 ● 005010 49

Element Identifier Description Values 2300A ORGANIZATION SUMMARY RMR Organization Summary Remittance Detail

RMR01 Reference Identification Qualifier IK RMR02 Reference Identification 10J01SANCTN821 RMR03 Payment Action Code PI – Pay Item RMR04 Detail Premium Payment Amount -100


2000B INDIVIDUAL REMITTANCE MEMBER #1 ENT Individual Remittance

ENT01 Assigned Number 1 ENT02 Entity Identifier Code 2J - Individual ENT03 Identification Code Qualifier EI – Employee Identification Number ENT04 Identification Code A01234567


NM101 Entity Identifier Code IL - Insured/Subscriber ID NM102 Entity Type Qualifier 1 - Person NM103 Name Last or Organization Name REGAN NM104 Name First RONALD NM105 Name Middle A NM108 Identification Code Qualifier N - Insured's Unique Identification

Number NM109 Identification Code A01234567

2300B INDIVIDUAL PREMIUM RMR Individual Premium Remittance Detail

RMR01 Reference Identification Qualifier AZ - Health Insurance Policy Number RMR02 Insurance Remittance Reference Number H19101FH0037918220091001 RMR04 Detail Premium Payment Amount 189.30

DTM Individual Coverage Period DTM01 Date/Time Qualifier 582 - Report Period DTM05 Date Time Period Format Qualifier RD8 DTM06 Date Time Period 20091001-20091014

2000B INDIVIDUAL REMITTANCE MEMBER#2 ENT Individual Remittance

ENT01 Assigned Number 2 ENT02 Entity Identifier Code 2J - Individual ENT03 Identification Code Qualifier EI – Employee Identification Number ENT04 Identification Code A07654321


NM101 Entity Identifier Code IL - Insured/Subscriber ID NM102 Entity Type Qualifier 1 - Person NM103 Name Last or Organization Name REGAN NM104 Name First NANCY NM105 Name Middle A


OCTOBER 2010 ● 005010 50

Element Identifier Description Values NM108 Identification Code Qualifier N - Insured's Unique Identification

Number NM109 Identification Code A07654321

2300B INDIVIDUAL PREMIUM OCCURRENCE #1 RMR Individual Premium Remittance Detail

RMR01 Reference Identification Qualifier AZ - Health Insurance Policy Number RMR02 Insurance Remittance Reference Number A191012H0037944520091001 RMR04 Detail Premium Payment Amount -194.06


2300B INDIVIDUAL PREMIUM OCCURRENCE #2 RMR Individual Premium Remittance Detail

RMR01 Reference Identification Qualifier AZ - Helath Insurance Policy Number RMR02 Insurance Remittance Reference Number A191012H0037944520091001 RMR04 Detail Premium Payment Amount 254.62


SE Transaction Set Trailer SE01 Number of Included Segments SE02 Transaction Set Control Number

4.1.2.3 BHS Example For BHS 820, Move (D Rec) ELG-GROUP+(D Rec) TOTAL-GROUP-CAP from SLN01:

1. Move the ELG-GROUP (or "MANUAL ENTRY") to be concatenated with the Invoice number in

2300/RMR02

2. Move the TOTAL-GROUP-CAP to the 2300/RMR04 to replace the INV-AMT-PAID. The INV-AMT-PAID

was equal to the BPR02 value for BHS.

Note:

1. The 2300A/RMR segment may occur more than 1x per 2000A/ENT loop.

2. Sum of all RMR04=BPR02




Number 00501 GS01 Functional Identifier Code RA GS02 Application Sender’s Code AHCCCS866004791 GS03 Application Receiver’s Code BHS079999


OCTOBER 2010 ● 005010 51

Element Identifier Description Values GS04 Functional group creation date CCYYMMDD GS05 Time 02190182 GS06 Group Control Number 294021901 GS07 Responsible Agency Code X GS08 Version / Release / Industry





Amount 1084309.97


Date 20091106




REF01 Reference Identification Qualifier 14-Master Account Number REF02 Premium Receiver Reference

Identifier 079999


Qualifier RD8


NAME


Organization Name DHS - BEHAVIOR HEALTH




1000B PREMIUM PAYER’S


OCTOBER 2010 ● 005010 52

Element Identifier Description Values NAME





2000A ORGANIZATION SUMMARY REMITTANCE

ENT Organization Summary Remittance

ENT01 Assigned Number 1 ENT02 Entity Identifier Code 2L- Corporation ENT03 Identification Code Qualifier FI – Federal Tax ID ENT04 Identification Code 866004791

2300A ORGANIZATION SUMMARY REMITTANCE DETAIL

>1 Occurrence #1

RMR Organization Summary Remittance Detail

RMR01 Reference Identification Qualifier IK – Invoice Number RMR02 Contract, Invoice, Account,

Group, or Policy Number TXXI KIDP00124334 (ELG-GROUP or “MANUAL ENTRY” +VOU-ID-BHS)

RMR03 Payment Action Code Not used RMR04 Detail Premium Payment Amount 1050536.48


Qualifier RD8

DTM06 Coverage Period 20091101-20091130 2310A SUMMARY LINE ITEM IT1 IT1 Segment - Summary Line

Item

IT101 Line Item Control Number Start with ‘1’ and increment 2315A MEMBER COUNT SLN SLN Segment - Member Count

SLN01 Line Item Control Number Start with ‘1’ and increment SLN03 Information Only Indicator O – Information Only SLN04 Head Count Group count SLN05 Unit or Basis for Measurement

Code IE - Person


Occurrence #2


OCTOBER 2010 ● 005010 53

Element Identifier Description Values DETAIL



Group, or Policy Number TXXI ADUP00124334 (ELG-GROUP or “MANUAL ENTRY” +VOU-ID-BHS)

RMR03 Payment Action Code Not used RMR04 Detail Premium Payment Amount 33773.49


Qualifier RD8

DTM06 Coverage Period 20091101-20091130 2310A SUMMARY LINE ITEM IT1 IT1 Segment - Summary Line

Item

IT101 Line Item Control Number 2 2315A MEMBER COUNT SLN SLN Segment - Member Count

SLN01 Line Item Control Number 2 SLN03 Information Only Indicator O – Information Only SLN04 Head Count Group count SLN05 Unit or Basis for Measurement

Code IE - Person


4.1.2.4 BHS Adjustment Example For BHS 820, Move (D Rec) ELG-GROUP+(D Rec) TOTAL-GROUP-CAP from SLN01:

1. Move the ELG-GROUP (or "MANUAL ENTRY") to be concatenated with the Invoice number in

2300/RMR02

2. Move the TOTAL-GROUP-CAP to the 2300/RMR04 to replace the INV-AMT-PAID. The INV-AMT-PAID

was equal to the BPR02 value for BHS.




Number 00501 GS01 Functional Identifier Code RA GS02 Application Sender’s Code AHCCCS866004791 GS03 Application Receiver’s Code BHS079999 GS04 Functional group creation date CCYYMMDD


OCTOBER 2010 ● 005010 54

Element Identifier Description Values GS05 Time 02190182 GS06 Group Control Number 294021901 GS07 Responsible Agency Code X GS08 Version / Release / Industry





Amount 1084309.97


Date 20091106





Identifier 079999


Qualifier RD8


NAME


Organization Name DHS - BEHAVIOR HEALTH






OCTOBER 2010 ● 005010 55

Element Identifier Description Values N1 Premium Payer’s Name







ENT01 Assigned Number 1 ENT02 Entity Identifier Code 2L- Corporation ENT03 Identification Code Qualifier FI – Federal Tax ID ENT04 Identification Code 866004791

2300A ORGANIZATION SUMMARY REMITTANCE DETAIL

>1



Group, or Policy Number MANUAL ENTRYMH012433200000 (ELG-GROUP or “MANUAL ENTRY” +VOU-ID-BHS)

RMR03 Payment Action Code Not used RMR04 Detail Premium Payment Amount 1185786.44 RMR05 Billed Premium Amount 11741526.72

2310A SUMMARY LINE ITEM IT1 IT1 Segment - Summary Line

Item

IT101 Line Item Control Number Start with ‘1’ and increment 2315A MEMBER COUNT SLN SLN Segment - Member Count

SLN01 Line Item Control Number Start with ‘1’ and increment SLN03 Information Only Indicator O – Information Only SLN04 Head Count Default to ‘0’ SLN05 Unit or Basis for Measurement

Code IE - Person

2320A ORGANIZATION SUMMARY REMITTANCE LEVEL ADJUSTMENT

ADX ADX Segment - Organization Summary Remittance Level Adjustment


OCTOBER 2010 ● 005010 56

Element Identifier Description Values ADX01 Adjustment Amount (ADJ-AMT + PREV-PD-

AMT + REM-BAL) * -1 ADX02 Adjustment Reason Code H6 – Partial Payment


4.1.2.5 CRS Example Element Identifier Description Values

ISA08 Interchange Receiver ID 990123456 (HP TAX ID; 3-character Health Plan acronym removed)


Number 00501 GS01 Functional Identifier Code RA GS02 Application Sender’s Code AHCCCS866004791 GS03 Application Receiver’s Code 010101 GS04 Functional group creation date CCYYMMDD GS05 Time 02190182 GS06 Group Control Number 294021901 GS07 Responsible Agency Code X GS08 Version / Release / Industry





Amount 376190.47


Date 20100210





Identifier 999111


OCTOBER 2010 ● 005010 57

Element Identifier Description Values DTM Coverage Period

DTM01 Date/Time Qualifier 582 - Report Period DTM05 Date Time Period Format

Qualifier RD8


NAME












ENT01 Assigned Number ENT02 Entity Identifier Code 2L – Corporation ENT03 Identification Code Qualifier FI – Federal TIN ENT04 Organization Identification Code 866004791

2300A Organization Summary

Remittance Detail 1st occurrence

RMR Individual Premium Remittance Detail


Group, or Policy Number CK0000116

RMR04 Detail Premium Payment Amount 0 (default) 2300A Organization Summary

Remittance Detail 2nd occurrence +

RMR Individual Premium Remittance


OCTOBER 2010 ● 005010 58

Element Identifier Description Values Detail


Group, or Policy Number %136013CRSL (Contract Type, Service Area, Enroll Rate Code, CRS Rate Code)

RMR04 Detail Premium Payment Amount -219.97 DTM Individual Coverage Period


Qualifier RD8

DTM06 Date Time Period 20090501-20090531 2300A Organization Summary

Remittance Detail Repeats



Group, or Policy Number %136013CRSL (Contract Type, Service Area, Enroll Rate Code, CRS Rate Code)

RMR04 Detail Premium Payment Amount -219.97 DTM Individual Coverage Period


Qualifier RD8

DTM06 Date Time Period 20090601-20090630 SE Transaction Set Trailer

SE01 Number of Included Segments SE02 Transaction Set Control Number

4.1.2.6 CRS Manual Payment Example Element Identifier Description Values



Number 00501 GS01 Functional Identifier Code RA GS02 Application Sender’s Code AHCCCS866004791 GS03 Application Receiver’s Code 010101 GS04 Functional group creation date CCYYMMDD GS05 Time 02190182


OCTOBER 2010 ● 005010 59

Element Identifier Description Values GS06 Group Control Number 294021901 GS07 Responsible Agency Code X GS08 Version / Release / Industry





Amount 2000


Date 20100210





Identifier 999111


Qualifier RD8


NAME







N1 Premium Payer’s Name


OCTOBER 2010 ● 005010 60

Element Identifier Description Values N101 Entity Identifier Code PR N102 Premium Payer Name AHCCCS





ENT01 Assigned Number ENT02 Entity Identifier Code 2L – Corporation ENT03 Identification Code Qualifier FI – Federal TIN ENT04 Organization Identification Code 866004791

2300A Organization Summary

Remittance Detail 1st occurrence



Group, or Policy Number CK0000116

RMR04 Detail Premium Payment Amount 2000 (Invoice Amount Paid; =BPR02)

RMR05 Billed Premium Amount 3000 (Invoice Amount)

ADX Organization Summary Remittance Level Adjustment

ADX01 Adjustment Amount -1000 (Difference of 2300A/RMR04 and RMR05)

ADX02 Adjustment Reason Code H6 – Partial Payment Remitted


4.1.2.7 Empty File Example Element Identifier Description Values


ISA11 Repetition Separator ^ ISA12 Interchange Control Version Number 00501 GS01 Functional Identifier Code RA GS02 Application Sender’s Code AHCCCS866004791 GS03 Application Receiver’s Code 010101


OCTOBER 2010 ● 005010 61

Element Identifier Description Values GS04 Functional group creation date CCYYMMDD GS05 Time 02190182 GS06 Group Control Number 294021901 GS07 Responsible Agency Code X GS08 Version / Release / Industry Identifier Code; no

addenda 005010X218

ST 820 Header ST01 Transaction Set Identifier Code 820 ST02 Transaction Set Control Number 000000001 ST03 Implementation Convention Reference 005010X218

BPR Financial Information BPR01 Transaction Handling Code I - Remittance Info Only BPR02 Total Premium Payment Amount 0 BPR03 Credit/Debit Flag Code C BPR04 Payment Method Code NON - Non-payment Data BPR10 Originating Company Identifier 1866004791 BPR16 Check Issue or EFT Effective Date 20091028

TRN Reassociation Trace Number TRN01 Trace Type Code 3 - Financial Reassociation Trace

Number TRN02 Reference Identification “NO DATA” TRN03 Originating Company Identifier 1866004791

REF Premium Receivers Identification Key REF01 Reference Identification Qualifier 14-Master Account Number REF02 Premium Receiver Reference Identifier 010101


1000A PREMIUM RECEIVER’S NAME N1 Premium Receiver’s Name

N101 Entity Identifier Code PE-Payee N102 Premium Receiver’s Last or Organization

Name “NO CAPITATION PAYMENT”

1000B PREMIUM PAYER’S NAME N1 Premium Payer’s Name



N4 Premium Payer’s City, State, Zip Code N401 City Name PHOENIX N402 State or Province Code AZ N403 Postal Code 85034



OCTOBER 2010 ● 005010 62

4.2 Payer Specific Business Rules and Limitations 4.2.1 834 Enrollment Transaction The 834 Enrollment Transaction transmits enrollment information from the sponsor of the insurance coverage (AHCCCS) to a health care payer (an AHCCCS Health Plan) on a daily and monthly basis. The daily version of this transaction provides data on initial enrollments, enrollment terminations, and subsequent changes to member-level enrollment data. The monthly version provides a listing of active members that is the basis for the health plan’s monthly capitation pre-payment.

The Daily 834 Enrollment Transaction is used to identify:

New members for whom the health plan is responsible Terminated or deceased members for whom the health plan is

no longer responsible Demographic changes for each member such as changes in

name, address or date of birth Other changes for each member such as changes in Rate

Code or TPL coverage

The Monthly 834 Enrollment Transaction is used to:

Reconcile health plan and AHCCCS member files Audit updates to health plan data applied from Daily 834

Transactions during the previous month

Member lines on both Daily and Monthly 834 Transactions carry Voucher Numbers when they result in capitation payments or adjustments. Corresponding Voucher Numbers also appear on payment lines in the 820 Capitation Payment Transaction and can be used to link enrollments to member level capitation payments.

4.2.2 820 Capitation Transaction The 820 Capitation Transaction is a weekly file that provides each AHCCCS health plan with an electronic remittance advice for its capitation payments. AHCCCS makes all capitation payments on a weekly basis with an electronic payment or check to each capitated health plan. The weekly 820 can accumulate and report capitation payments generated during the prior week by Daily Rosters, Monthly Rosters, and ad hoc Mass Adjustment Files. Financial sanctions and other payments to and recoupments from health plans that are not member specific can also be carried on the 820. Partial capitation


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payments can be accommodated on the 820 as organization level negative payments.

The AHCCCS Division of Budget and Finance (DBF) control payment data on the 820 through the Oracle Financial System. Finance specifies the Oracle Invoice Numbers (derived from Voucher Numbers generated in PMMIS) to be included in each weekly payment. Although more than one Invoice Number can appear on a Roster, Finance specifies Invoice Numbers in a way that includes full Daily Roster data in each payment. Rosters are not normally split between payments.

Finance makes an exception to the weekly payment inclusiveness rule for Daily or Mass Adjustment Rosters that result in negative payments to a health plan. Because payments cannot be made for negative amounts, these rosters are saved for payment until the next Monthly Pre-Payment Cycle when the payment total is certain to be higher than any negative adjustment.

The 820 Transaction is used to:

Show monthly capitation pre-payments for each health plan member

Show pro-rated payments for each health plan member who joined during the previous month

Show positive or negative adjustments that reflect changes to previous capitation payments

Show positive or negative Rate Code adjustments based on retroactive capitation rate changes by AHCCCS (mass adjustments)

Show AHCCCS payments and recoveries that are not member specific, including financial sanctions imposed by AHCCCS due to late encounter submission

For AHCCCS, the concept of retroactive capitation adjustments is different from the adjustments to current payments supported by the 820 Transaction. For this reason, payments and recoupments reported on the 820 are always considered original payments rather than 820 adjustments.


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4.3 Frequently Asked Questions None available at this time.

4.4 Other Resources 4.4.1 AHCCCS Action Code Translation Table

Action Type

Action Code

Description 834 Translation/Maintenance Reason Code Value

A $P Manual Payment 820 Transaction – no map for 834. A AA Algorithm Assigned Mapped to HD04 in the 2300 Loop.

28 – Initial Enrollment A AI Admin-In 28 – Initial Enrollment A BI Enrollment Block In 28 – Initial Enrollment A CI County Move-In 28 – Initial Enrollment A EC Enrollment Choice Mapped to HD04 in the 2300 Loop

28 – Initial Enrollment A EI Open Enrollment-In The health plan will receive a Potential

Transition Listing separately. 28 – Initial Enrollment

A FI Family Continuity-In 28 – Initial Enrollment A MI Medical Care Continuity-In 28 – Initial Enrollment A MR Mass Adjustment Recoupment 820 Transaction – no map for 834 A NB Newborn 02 - Birth A NE Normal Enrollment 28 - Initial Enrollment A NP Normal Enrollment Prior Plan 28 – Initial Enrollment A PA End of Contract-In - Auto Ass 28 – Initial Enrollment A PD End of Contract- In - Direct 28 – Initial Enrollment A PP End of Contract- In - Percent 28 – Initial Enrollment A PR End of Contract - In - Rule M 28 – Initial Enrollment A RA Retroactive Enrollment 28 – Initial Enrollment A RE Re-Enrollment 41 - Re-enrollment

C AC Address Change 43 - Change of location C C1 "Combination Action Code"

DB, NC, SX 25 - Change in Identifying Data Element

C C2 "Combination Action Code" DB, NC


C C3 "Combination Action Code" DB, SX


C C4 "Combination Action Code" NC, SX


C CP Co-pay Change 33 - Personnel Data C DB Date of Birth Change 25 - Change in Identifying Data Element C HC Acute Health Plan Change 22 – Plan Change C HK Hospital Kick 820 Transaction – no map for 834 C IC SSN Change Not Used


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Action Type

Action Code

Description 834 Translation/Maintenance Reason Code Value

C MC Mental Health Change A separate 2300 loop with HD03 = "AK" 22 – Plan Change

C NI NICU Change Not Used

C NC Name Change 25 - Change in Identifying Data Element

C OC Other Change Not Used C PG Pregnant Women Create a separate 2300 loop with HD03 =

"AG". AI – No Reason Given

C RC Rate Code Change 29 - Benefit Selection C SB Supplemental Birth Payment 820 Transaction – no map for 834 C SC Share of Cost Change 33 - Personnel Data C SX Sex Change 25 - Change in Identifying Data Element

C TM Mental Health Termination 22 – Plan Change

C NONE FYI Changes AI – No Reason Given C NONE TPL Changes AI – No Reason Given

D $R Manual Recoupment 820 Transaction – no map for 834 D AE Applied for New Eligibility 07 – Termination of Benefits D AO Admin Out 22 - Plan Change D BO Enrollment Block Out Maintenance Reason Code will be blank

Plans do not receive now D CH Eligibility Change - Disenroll 07 – Termination of Benefits D CO County Move-Out 22 – Plan Change D DE Deceased 03 - Death D EO Open Enrollment-Out The Health Plan will still receive Potential

Transition Listing separately. 07 – Termination of Benefits

D FO Family Continuity-Out 07 – Termination of Benefits D HO Move out of Health Plan Area 07 – Termination of Benefits D IE Ineligible 07 - Termination of Benefits D MA Mass Adjustment Recoup 820 Transaction – no map for 834 D MO Medical Care Continuity-Out 07 – Termination of Benefits D OS Out of State Move 07 – Termination of Benefits D PO End of Contract - Out - Direct 07 – Termination of Benefits D PT End of Contract-Out - %, AA, 07 – Termination of Benefits D RO Recoupment MHS 820 Transaction – no map for 834 D VW Voluntary Withdrawal 14 - Voluntary Withdrawal


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5. TI Change Summary # Location Previously Stated Revision

arizona health care cost containment system … · arizona health care cost containment system...

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